Are you currently pregnant? *

Yes

No

Do you carry a medical warning card? *

Yes

No

Are you receiving treatment from a hospital or a clinic? *

(If yes, please provide details in the box below)

Yes

No

Do you suffer from hay fever or eczema? *

Yes

No

Do you suffer from bronchitis, asthma or other chest conditions? *

(If yes, please provide details in the box below)

Yes

No

Are you allergic to any medicine, tablets, substances or latex? *

Yes

No

At present, are you taking any medicine or tablets? *

(If yes, please provide details in the box below)

Yes

No

Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? *

Yes

No

Do you suffer from heart problems, angina, blood pressure problems, or stroke? *

Yes

No

Are you diabetic? *

Yes

No

Do you suffer from arthritis? *

Yes

No

Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery? *

Yes

No

Do you suffer from any infectious diseases (including HIV and hepatitis)? *

Yes

No

Have you ever had rheumatic fever or cholera? *

Yes

No

Have you ever had liver disease or kidney disease? *

Yes

No

Have you had any other serious illness? *

Yes

No

Have you ever had a bad reaction to general or local anesthetic? *

Yes

No

Have you ever had a joint replacement or other implant?

Yes

No

In the past 2 years have you undergone any operations? *

(If yes, please provide details in the box below)

Yes

No

Have you ever been treated with hydro-cortisone or corticosteroids? *

Yes

No

Do you smoke? *

Yes

No

What is your average weekly consumption of alcohol? *

Everyday

A few times each week

A few times each month

Never

I confirm that the above form has been completed accurately and to the best of my knowledge: *